End of Life Care

The War That No One Wins

My uncle just died.  He was my mother's brother,  an irascible blowhard, a mercurial bit of a family dictator with a soft spot for small children. He had the unfortunately common clinical course of catastrophic illness followed by steadfast decline into the heartbreaking oblivion of dementia. This dementia was of a steep descent and his daily life was reduced to a nursing home, albeit one where my mother and his wife visited multiple times a day and advocated fiercly for adequate care. On Sunday he suddenly vomited, was noted to be febrile and tachypneic. He was, sensibly enough, a DNR with a "no transfer" to hospital order on the chart-though not in hospice care. His oxygen saturations fell to critical levels despite aggressive supplemental oxygen, and he began to struggle for breath. His breathing was noisy, and he developed tremendous secretions which he was unable to clear. My mother, at…

Mother Knows Best

My 85 year old patient was brought in from home.  She was cachectic, contracted, minimally responsive to questions, covered in multiple decubitus ulcers on both hips, both knees, both shoulders, and her sacrum.  She had polymicrobial sepsis-bacteremic with two different organisms. She was, in fact, dying. Despite her profoundly debilitated condition,  her son, who cared for her at home wanted "everything" done.  So she was placed on IV fluids, antibiotics, received an infectious disease consult, had a tunneled line placed, was started on TPN etc., etc.  The medical team had a family conference, but could not dissuade the family from the aggressive plan of care to "do everything."  An ethics consult was called.  No decisions to change the plan of care were made.  Ultimately the patient did improve somewhat, but she was stuck in the hospital as it was felt to be "unsafe" to discharge her home, without hospice level…

Prioritizing Inpatient Geriatric Care Is NOT a Moon Shot.

Most physicians recognize the JNC guideline for blood pressure management, or the ACCP thrombosis guideline for VTE.  Most would agree we use a handful of accepted benchmarks to manage a limited number of conditions.  For the rest, it’s the wild wild west. Try to develop consensus around delirium management or treatment of alcohol withdrawal, and you will likely find yourself on the road to nowhere. If you have never visited The National Guideline Clearinghouse, you should have a peek.  Sometimes I find the site helpful for a management dilemma or patient with a rare presentation. However, for most, the compilation runs endlessly long and you will begin a convoluted journey if you crave a solution.  The same road to nowhere. As of this writing, the database has close to 2400 entries.  Have fun with that: (more…)

A Battle of Wills

Through our careers, we all accumulate memorable patients. This month’s post is dedicated to the memory of “Henrietta” (not her real name) who died recently and had an impact on my life. I would never claim to know all about her - we only met in the medical realm, after all, but I am grateful that I had a chance to get to know her at least a little bit over the past many months, and I wish we had had a chance to meet outside the hospital. Henrietta was the one running the show over many long hospital stays. Nobody was going to steer her course on good or bad days. Discharge today - I don’t think so. Things aren’t looking good with this cancer - I’m not hearing any negativity today. A new medication for symptoms - no thanks.   I think I should call your family – no,…

The Shield

Recently I received an elderly patient who had been transferred from another hospital where she had been admitted for two weeks. The pertinent information about this patient is that her son, a doctor, a pathologist, had arranged the transfer. The worst thing to have is a patient with a doctor for a relative. No, the worst thing is to have a patient with a doctor who is a pathologist for a relative. I had already heard from the night doctor about how difficult and “micro-managey” the son was, how he walked around the hospital wearing his stethoscope (...pathologists don’t use stethoscopes). So before I even saw the patient I was aggravated and loaded for bear, filled with a bit of self-righteous anger. I was going to “set some limits” with the son. I was not going to let him take over her care. When I complained about the situation, before…